Ryan W. Bearer, DO, MPH, MS Matrix Pain Management PC Saginaw, MI

Ryan W. Bearer, DO, MPH, MS Matrix Pain Management PC Saginaw, MI

Consultant for Depomed Consultant for Stryker

Fibromyalgia Chronic pain disorder which results in Widespread hypersensitivity Sleep disorders Abnormal thinking Fatigue Can also result in Depression/anxiety IBS or GI complaints Pelvic pain Migrane/tension headaches Irritable bladder TMJ

Guillaume de Baillou circa 1592 Rheumatism Muscular pain and acute rheumatic fever 1700 s Articular rheumatism Painful deforming condition of joints Muscular rheumatism Painful nondeforming soft tissue disorders

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Literature published on muscular rheumatism from German, Scandinavian, and British physicians William Balfour 1815 Nodules were the result of inflammation in muscle connective tissue 1824 Focal tenderness in muscles first referred to as tender points François Valleix 1841 painful points in the body referred to other areas on palpation Suggested muscular rheumatism as a form of neuralgia

Inman 1858 trigger point radiation independent of nerves Functional change due to spasm Beard 1880 relation of widespread pain, fatigue, and psychological disturbance Neurasthenia Myelasthenia Attributed to stresses of modern life

http://www.mdjunction.com/forums/fibromyalgia-mediscussions/general-support/10465518-tender-point-locations http://championschiropractic.com/archives/268

Cornelius 1903 local tender points from hyperactive nerve endings called nerve points Hyperactivity due to external stimuli Climate Emotional Exertion

Sir William Gowers 1904 We are thus compelled to regard lumbago in particular, and muscular rheumatism in general, as a form of inflammation of the fibrous tissues of the muscles (and thus)...we may conveniently follow the analogy of cellulitis and term it fibrositis. Spontaneous pain Sensitivity to compression Fatigue Sleep disturbance Exaggeration by acute/chronic cold and overstrain

Treatment Manipulation Counterirritation Cocaine injections Failure of salicylates Stockman 1904 Provided pathologic basis for Gowers inflammation theory from myalgic muscle biopsies Mayo clinic physicians reexamined Stockman sections and could not corroborate the findings

Sir William Osler 1909 Fibrositis was nothing more than neuralgia of sensory nerves of the muscles Lack of laboratory tests Uncertain histologic changes Uncertain physical findings Led to non recognition by north American physicians Kellgren 1937 injected hypertonic saline into muscle groups and interspinous ligaments and proved radiating patterns

Kelly 1941 proposed the somatovisceral reflex theory Information from tender points caused a CNS reflex of deep pain and hyperalgesia Suggested local anesthetic injection Travell and Rinzler 1940 s published work on myofascial trigger points and myofascial pain syndrome Described myofascial trigger point referral patterns

World war II Growing interest as 70% of british troops admitted to a hospital had fibrositis 5.8% of American soldiers admitted diagnosed with fibrositis Copeman and Pugh 500 soldiers seen whereby the number of nodules were equal between those with and without fibrositis 10 times the amount of tender/trigger points in fibrositis pts. 30% vs. 3%

Traut 1968 described first modern day description of Fibromyalgia (FMS) Female gender Generalized aching and stiffness Fatigue Headaches Colitis Poor sleep worry worts Tender points Described mind-body interaction in pathogenesis of FMS

Smythe Grandfather of modern day FMS Late 70 s 10 page chapter in popular rheumatology text First to describe as generalized pain syndrome Described the tender points which would serve for the 1990 classification system Published EEG sleep studies Decreased stage 3 and interruption of NREM by alpha rhythms Healthy control volunteers had their NREM interrupted by auditory stimuli In the morning healthy volunteers had increased fatigue, aches and stiffness, tenderness, and worse mood symptoms

1976 fibromyalgia began acceptance as the new term for fibrositis Yunus 1981 first controlled study of clinical characteristics In addition to the previously described symptoms, fibrositis patients showed: Subjective swelling of tissues Paresthesias IBS Tension type and migranous headaches

1980 s histologic studies of muscle biopsies Pathologists blinded No histologic difference in trapezius muscle biopsies 1984 interrelation of central pain syndromes and their overlap was first suggested by Yunus

1983 Campbell published diagnostic criteria in JAMA 3 obligatory criteria: Chronic, generalized aches, pains, or stiffness involving 3 or more anatomic sites for at least 3 months Presence of multiple tender points at characteristic locations Absence of another systemic condition that could account for the symptoms Some combination of 6 minor criteria Disturbed sleep Generalized fatigue or tiredness Subjective swelling and numbness Pain in neck and shoulders Chronic headaches Irritable bowel symptoms

1990 ACR criteria Widespread pain occurring for greater than 3 months Above and below the waist Palpation of 4kg/cm 2 pain in 11/18 standardized tender points Could not have another disease which could explain the symtoms

1992-4 Russell published data on neurotransmitter changes Increased substance P in CSF Decreased serotonin in CSF 1993 Granges and Littlejohn using innocuous electrical stimuli Decreased spinal flexion reflex Decreased pain threshold Pressure Hot Cold

1993 Griep published data on alteration of the hypothalamic-pituitary-adrenal axis Hyperactive release of ACTH Hyporesponsiveness of adrenal cortex 1995 Mountz PET scanning brains in FMS Decreased cerebral blood flow in thalamic and caudate nuclei

2000 Martinez-Lavin and Hermosillo role of autonomic nervous system Sympathetic overactivity 2002 Gracely 3 provided painful stimulus to FMS patients and controls Measured cerebral activity using fmri Significantly increased signal in areas of brain not found in controls

Numerous changes occurred over a 10 year period Tender point exam was difficult to perform Often missed clinically significant FMS Men have less tender points than women Removed the criteria for a diagnosis of exclusion Removed the 18 classic points to just pain above and below the diaphragm

2011 Wolfe studied the new ACR criteria in over 7 thousand FMS and other rheumatologic patients Tender point exam had a lot of interprovider variation Men tend to have less tender points More emphasis of symptom severity Created the widespread pain index Created the symptom severity scale

2-8% of the population Female : male = 2 : 1 Can develop at any age Similar prevalence in different Countries Cultures Ethnic groups May occur with other chronic pain conditions 10% - 30% of patients with OA, RA, SLE meet FMS criteria

May present or have history of other systemic complaints Headaches Dysmenorrhea Temporomandibular joint disorder Chronic fatigue Irritable bowel syndrome Other gastrointestinal complaints Regional pain syndromes Back neck

Psychological, behavioral, and social issues Contribute to the pathogenesis Barriers to treatment More likely to have psychiatric disorders Depression Anxiety Obsessive-compulsive disorder Post traumatic stress disorder

Team based approach Mild symptoms can be managed in primary setting Referral for diagnostic uncertainty Refractory to therapy Treatment of underlying psychiatric disorder Education Disease is not due to damage and not progressive Engagement in self care Stress reduction Sleep Exercise

Agents that reduce excitatory neurotransmitters Gabapentin (Neurontin) Pregabalin (Lyrica) FDA approved Agents that increase inhibitory neurotransmitters like serotonin and norepinephrine Tricyclic antidepressents Amitriptyline (Elavil) Nortriptyline (Pamelor) Cyclobenzaprine (Flexeril)

Bicyclic antidepressants Duloxetine (Cymbalta) FDA approved Milnacipran (Savella) FDA approved Venalafaxine (Effexor) Desvenlafaxine (Pristiq) Mirtazapine (Remeron)

Monocyclic antidepressants Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Opiate antagonists Low dose naltrexone 7 30% reduction in pain Improved general satisfaction with life Improved mood

Non steroidal Antiinflammatory drugs Steroids OPIOIDS Result in upregulation of NMDA receptor NMDA receptor found to be related to hyperalgesia Studies show opiates can worsen fibromyalgia related hyperalgesia and other central pain states 7

Magnitude of response greater than for the pharmacologic Greatest benefit in improved function Result in the most sustained improvement Adherence and access most important limitations Education Some feel that the label of fibromyalgia may worsen the symptoms Studies show that establishing the diagnosis can provide relief

Cognitive behavioral therapy Type of psychotherapy which addresses Maladaptive behaviors Dysfunctional emotions Cognitive process Problem focused Action oriented Some behaviors cant be controlled through rational thought Select strategies to address issues Poor acceptance when viewed as psychological intervention

Exercise Aerobic exercise the best studied Strengthening and stretching of value Inactivity leads to a snowball effect Especially as we age Exercise tolerance Increasing daily activity may be better starting point Walk a block daily for a week Then 1.5 blocks daily for a week Muscle strain can result in set backs

FM/a test 8 Based on theory that there is a impaired immune response in FMS Peripheral blood is taken and mononuclear cells isolated Baseline cytokine levels measured Subjected to mitogen activators Stimulated cytokine levels are again drawn FMS patients had significantly decreased cytokine levels post stimulation from controls

FM/a test $744.00 Would we see the same results in other pain disorders? Patients were selected who had no other comorbid disease states No immune deficiencies Not on steroids No other rheumatologic disorder Small fiber polyneuropathy 8 Patients with FMS were 14 times more likely to have concomitant SFPN vs controls 2 patients had HepC, 8 with immune disorder, 1 with genetic disorder

AV shunts in skin of women with fibromyalgia have increased sensory fiber innervation 9 Alters sensory function in hands May alter muscle blood flow and explain fatigue and widespread muscle pain through ischemia

1. Inanici F1, Yunus MB. History of fibromyalgia: past to present. Curr Pain Headache Rep. 2004 Oct;8(5):369-78. 2. Boomershine, CS. Fibromyalgia Diagnosis: Moving Beyond Tender Points. Pain Medicine News Special Edition. 2012 December; 50-6. 3. Gracely RH, Petzke F, Wolf JM, Clauw DJ: Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum 2002, 46:1333 1343 4. Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria nd severity scales for clinical and epidemiological studies: a modificationof the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol. 2011;38(6):1113-22. 5. Wide spread pain indes 6. Claw, DJ. Fibromyalgia A Clinical Review. JAMA. 2014 April 16; 311(15) 1547-54. 7. Younger J, Noor N, CcCue R, Mackey S. Low-dose naltrexone for the treatment of fibromyalgia: findings of a small, randomized, double-blind, placebo-controlled, counterbalanced, crossover trial assessing daily pain levels. Arthritis Rheum. 2013;65(2):529-38. 8. Oaklander AL, Herzog ZD, Downs HM, Klein MM. Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia. Pain 2013 Nov;154(11):2310-6. 9. Albrecht PJ, Hou Q, Argoff CE, Storey JR, Wymer JP, Rice FL (2013). Excessive Peptidergic Sensory Innervation of Cutaneous Arteriole-Venule Shunts (AVS) in the Palmar Glabrous Skin of Fibromyalgia Patients: Implications for Widespread Deep Tissue Pain and Fatigue. Pain Medicine, Vol. 14, Issue 6, Pages 895-915.